OCCUPATIONAL HEALTH DEPARTMENT Level 10 CSB, University of H !!ersfiel!, " eens#$te, H !!ersfiel!

, HD1 %DH& Tel' 01()( (*1)00

DECLARATION OF HEALTH INITIAL TEACHER TRAINING / TEACHER TRAINING FOR FURTHER EDUCATION, GUIDANCE, YOUTH & COMMUNITY WORK AND RELATED COURSES
STRICTLY CONFIDENTIAL

Please com le!e !"#s $o%m #& $'ll a&( )%#&* !o +o'% U&#,e%s#!+ #&!e%,#e- a&( "a&( #& a! %ece !#o&. I$ +o' a%e '&a)le !o )%#&* !"e $o%m !o +o'% #&!e%,#e- a&( +o' a%e o$$e%e( lace lease se&( !"e com le!e( $o%m !o !"e a((%ess a)o,e.
T+e ,ontents of t+is for- .ill /e ,onfi!enti$l to t+e o,, 0$tion$l +e$lt+ servi,e $n! .ill not /e reve$le! to $nyone else .it+o t yo r .ritten ,onsent& T+e niversity is re#istere! .it+ t+e D$t$ Prote,tion Co--issioner to 0ro,ess !$t$ $n! $ny 0erson$l !$t$ s 00lie! .ill /e +el! stri,tly in ,onfi!en,e .it+ , rrent D$t$ Prote,tion le#isl$tion& 11111111111111111111111111111111111111111111111111111111111111111111111111111111 Pe%so&al De!a#ls /#& )loc0 le!!e%s1 S!'(e&! &'m)e% / lease %#&!12 S rn$-e&&&&&&&&&&&&&&&22&&&&&&&&&&&&&&&&&&&222222222222&&Title 2&& 2&&&2222222222&&

3oren$-es &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&22222222 D$te of Birt+&&&&&&&&&& 2&&&&&&&&&&&&&&&&&&&&&&&& Ho-e A!!ress&2222222222222&&&&&&&&&&&&&&&&&&&&&&&& 22222222222222222&& 2222222222222222222222222&& 2222222222222222222 Post Co!e 2222222222&&&2 Tel No 4D$yti-e5 2222222&&22222222&& 222&& P%ese&! occ' a!#o& 2222222222222222222&&22222& 2222222222& 33333333333333333333333333333333333333333333333333333333333333333333333333333333 Co'%se (e!a#ls T#!le o$ co'%se' CertE!6P7CE 0re8servi,e 4Lifelon# Le$rnin#5 9 " eens#$te ,$-0 s CertE!6P7CE 0re8servi,e 4Lifelon# Le$rnin#5 9 University Centre B$rnsley E$rly :e$rs BA 9 University Centre B$rnsley E$rly :e$rs BA 4to08 05 9 University Centre B$rnsley :o t+ $n! Co-- nity ;or< BA 4Hons5 Pri-$ry E! ,$tion 4E$rly :e$rs $n! =ey St$#e 15 BA 4Hons5 Pri-$ry E! ,$tion 4E$rly :e$rs $n! =ey St$#e 15 P7CE Se,on!$ry P7CE 8 B siness E! ,$tion 8 Desi#n Te,+nolo#y 8 ICT $n! Co-0 ter S,ien,e 8 ICT 8 M$t+e-$ti,s 8 M si, 8 S,ien,e .it+ C+e-istry 8 S,ien,e .it+ Biolo#y
L'>O,,8He$lt+>OH !o,s 8 , rrent>"(( SEPD He$lt+ " estionn$ire ?@ 1)&1A&1A&!o, P$#e 1 of B

T#c0 -"#c" o&e a l#es

8 S,ien,e .it+ P+ysi,s P7CE vi$ S,+ool Dire,t 4st$te 0ri-$ry6se,on!$ry $n! s /Ce,t5 E$rly :e$rs Profession$l St$t s E$rly :e$rs Profession$l St$t s 4;$<efiel! Colle#e5 A*e %a&*e o$ c"a%*es / !eac"#&* *%o' s2 PLEASE ANSWER ALL OF THE FOLLOWING 4UESTIONS. IF YOU ANSWER YES TO ANY 4UESTION PLEASE GI5E FULL DETAILS IN THE SPACE PRO5IDED ON THE NE6T PAGE. YES 1 A % ( B @ * ) E 10 11 1A 1% 1( 1B 1@ 1* 1) 1E A0 A1 AA A% A( AB H$ve yo ever +$! $ny illness, -e!i,$l 0ro/le- or !is$/ility t+$t -$y , rrently $ffe,t yo r $/ility to st !y or .or< s$fely $s $ te$,+erD H$ve yo ever /een tre$te! in +os0it$lD H$ve yo seen $ !o,tor in t+e 0$st ye$r for $ny +e$lt+ 0ro/le-D Are yo +$vin# $ny tre$t-ent or investi#$tions of $ny <in! $t t+e -o-entD Are yo .$itin# for $ny tre$t-ent, o0er$tion or investi#$tionD H$ve yo ever +$! $ny illness or +e$lt+ rel$te! 0ro/le- t+$t -$y +$ve /een ,$ se! or -$!e .orse /y yo r .or<D H$ve yo ever /een -e!i,$lly retire! fro- $ny Co/, or left $ny Co/ /e,$ se of ill +e$lt+D H$ve yo +$! $ny !$ys off si,< in t+e l$st A ye$rsD If yes, 0le$se #ive n -/er of !$ys $n! re$sons to t+e /est of yo r re,olle,tion Do yo +$ve $ny eyesi#+t 0ro/le-s not ,orre,te! .it+ #l$sses or ,ont$,t lensesD Do yo +$ve $ny +e$rin# 0ro/le-sD Do yo +$ve $ny !efe,t of s0ee,+ or ,o-- ni,$tion 0ro/le-D Do yo +$ve $ny !iffi, lties st$n!in#, /en!in#, liftin# or .it+ $ny ot+er -ove-entsD H$ve yo ever +$! $ny /$,< 0ro/le-D H$ve yo ever +$! $ny 0ro/le- .it+ yo r Coints in,l !in# 0$in, s.ellin# or stiffnessD H$ve yo ever +$! $ny -ent$l illness, 0sy,+olo#i,$l or 0sy,+i$tri, 0ro/lereF irin# +os0it$lis$tionD H$ve yo ever +$! !e0ression or $nGiety reF irin# -e!i,$tion or ,o nsellin#D H$ve yo ever +$! $n e0iso!e of self +$r-D H$ve yo ever t$<en $n over!oseD H$ve yo ever +$! $n e$tin# !isor!er e# $noreGi$ or / li-i$D H$ve yo ever +$! $ !r # or $l,o+ol 0ro/le-D H$ve yo ever +$! fits, /l$,<o ts or e0ile0syD H$ve yo ever +$! $ny s<in 0ro/le-sD H$ve yo ever +$! si#nifi,$nt or 0rolon#e! f$ti# e or 0ost vir$l syn!ro-e 4M&E&5D H$ve yo ever +$! $ny +e$rt or /loo! 0ress re 0ro/le-sD H$ve yo ever s ffere! fro- $st+-$, /ron,+itis or ,+est 0ro/le-sD NO

L'>O,,8He$lt+>OH !o,s 8 , rrent>"(( SEPD He$lt+ " estionn$ire ?@ 1)&1A&1A&!o, P$#e A of B

A@ A*

In t+e l$st 1A -ont+s, +$ve yo +$! $ ,o #+ for -ore t+$n % .ee<s, ,o #+e! 0 /loo! or +$! $ny neG0l$ine! .ei#+t loss or feverD H$ve yo ever +$! +e0$titis or C$ n!i,eD YES NO

A) AE %0 %1

Do yo +$ve $ny $ller#iesD Do yo +$ve $ny ot+er -e!i,$l ,on!itionsD Are yo on $ny -e!i,$tion $t 0resentD Do yo nee! or .o l! it $ssist yo to +$ve $ny s0e,i$l 0rovision -$!e to en$/le yo to f lfil yo r tr$inin# $n!6or s /seF ent e-0loy-entD

IF YOU HA5E ANSWERED 7YES8 TO ANY OF THE PRE5IOUS 4UESTIONS PLEASE GI5E AS MUCH DETAIL AS POSSI9LE 9ELOW. THIS MAY INCLUDE SOME OF THE FOLLOWING POINTS ' ;+$t .$s t+e !i$#nosisD ;+en .$s t+e !i$#nosis -$!eD Ho. lon# !i! it l$stD H$s it resolve!D ;$s it rel$te! to 0ro/le-s $t .or<D Di! it ,$ se yo to t$<e ti-e $.$y fro- .or<D If so, for +o. lon#D H$s it +$00ene! -ore t+$n on,eD ;ere yo $!-itte! to +os0it$lD Are yo still seein# $ S0e,i$listD Di! yo see or $re yo seein# $ny ot+er t+er$0e ti, s0e,i$list e&#& ,o nsellorD Di! yo t$<e $ny -e!i,$tionD

4'es!#o & &'m)e%

L'>O,,8He$lt+>OH !o,s 8 , rrent>"(( SEPD He$lt+ " estionn$ire ?@ 1)&1A&1A&!o, P$#e % of B

Co&!#&'e o,e%lea$ #$ &ecessa%+ Co&!#&'e "e%e #$ &ecessa%+ 4'es!#o & &'m)e%

SECTION E : Decla%a!#o&
I !e,l$re t+$t $ll t+e st$te-ents on t+e 0ro,ee!in# 0$#es of t+is for- $re tr e $n! ,o-0lete to t+e /est of -y <no.le!#e $n! /elief, $n! I $- $.$re t+$t $ny f$lse st$te-ents -$y $ffe,t -y $00li,$tion or ,ontin $tion on t+e ,o rse& I n!erst$n! t+$t t+is +e$lt+ !e,l$r$tion -$y /e for.$r!e! to $n O,, 0$tion$l He$lt+ P+ysi,i$n involve! in t+e $ssess-ent of -y fitness for t+e role !es,ri/e! $n! I #ive -y ,onsent for t+is to t$<e 0l$,e& I n!erst$n! t+$t no -e!i,$l !et$ils .ill /e !iv l#e! .it+o t -y 0er-ission to $ny ot+er 0erson o tsi!e t+e O,, 0$tion$l He$lt+ De0$rt-ent, / t $n o0inion $/o t -y fitness to n!ert$<e t+e 0ro0ose! ,o rse .ill /e #iven to t+e A!-issions Te$-& I n!erst$n! t+$t I -$y /e reF ire! to $tten! for $ -e!i,$l eG$-in$tion or $ssess-ent& I n!erst$n! t+$t if -y +e$lt+ st$t s $lters si#nifi,$ntly /et.een no. $n! ,o-0letin# t+e ,o rse !et$ile! I $- n!er $n o/li#$tion to $!vise T+e O,, 0$tion$l He$lt+ De0$rt-ent& After ,o-0letin# t+e .+ole of t+is +e$lt+ F estionn$ire, 0le$se t$<e $ 0+oto,o0y for yo r o.n re,or!s $n! ret rn t+e ori#in$l $s reF este! on 0$#e 1& Si#ne!222222222222222222222222 D$te222222222222222

L'>O,,8He$lt+>OH !o,s 8 , rrent>"(( SEPD He$lt+ " estionn$ire ?@ 1)&1A&1A&!o, P$#e ( of B

3or offi,e se only D$te entere! on COHORT' P+one in' :es 6 No D$te ,le$r$n,e e-$ile! to ,ont$,t'

S,reene! /y OHNA6OHMA' See OH' :es 6 No D$te ,le$re! OHNA6OHMA'

L'>O,,8He$lt+>OH !o,s 8 , rrent>"(( SEPD He$lt+ " estionn$ire ?@ 1)&1A&1A&!o, P$#e B of B